Medicines Management Policy - Dudley Primary Care Trust

occurs, and by whom, will need to take account of the nature of the error and
any adverse consequences suffered by the patient. Any discussions should be
documented in the patient's case notes.
11.2 Consequences of an error
Actions following an error may range from a review of processes, assessment
of individual accountability and training needs to a report to the National Patient
Safety Agency on the circumstances. Professionals may be referred to their
professional body. Repeated errors may lead to performance management
processes being activated.
11.3 Errors by Medical staff
The Medical Director will have responsibility for investigating the incident and
reporting the incident following the Incident Procedure.
11.4 Dispensing errors
In the case of a suspected dispensing error the medicines must be quarantined
immediately. The Pharmacist in Charge of either the hospital or community
pharmacy, from where the drug was dispensed, must be contacted for advice
on the action required concerning the drug and obtaining a replacement. If the
drug has been administered then the action laid out in 11.1 must be followed.
If the drug has not been administered the Medicines Management Team must
be contacted for advice, as above. The incident should be reported via sentinel
and documented in the patient/client’s records. The Clinical Governance Team
will advise on any risk management issues arising from an incident.
If the dispensing pharmacy is closed then the error must be reported the next
working day.
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